Published: Saturday, April 20, 2013 at 4:32 p.m.

Last Modified: Sunday, April 21, 2013 at 9:01 p.m.

But at the Daytona Methadone Treatment Center, more than 100 people stand in line for their daily dose of methadone, a drug that helps quell cravings for heroin and oxycodone.

The orange glows from cigarettes puncture the darkness as a security guard paces in the parking lot. A few people sit in chairs near the entrance of Florida's second-busiest clinic like Black Friday shoppers waiting for a doorbuster sale.

But this isn't a holiday. It's not a special occasion. For these people, it's a daily ritual.

As part of the $14 people pay for their daily methadone dose, clients are supposed to have access to counselors to help them with their recovery.

Yet counselor caseloads at Daytona Beach's methadone clinic have been two to three times higher than what they are supposed to be under state regulations, records show. And fewer than 2 percent of the 1,800 clients served by the clinic were weaned off the drug or successfully discharged from the program during the 2011-12 fiscal year, the last year for which records are available.

Methadone treatment is seen by the Centers for Disease Control and Prevention and others as an intervention that helps addicts get their lives back. One advocate who's taken a daily dose of the drug for more than 40 years says methadone saved her life.

At the same time, the treatment has long faced backlash from critics who say it simply swaps one drug for another. For-profit providers like Orlando-based Colonial Management Group, the company that runs the Daytona clinic, have come under fire from those who view them as "dose-and-go" operations that put profits ahead of patient care.

In Minnesota, inspectors are in the process of revoking the license of a Colonial Management methadone clinic where counselors had similarly high caseloads and other compliance issues.

In Florida, though, regulators rewarded the Daytona Beach clinic with a performance rating of 94 out of a possible 100 points.

A FOR-PROFIT BUSINESS

Methadone maintenance treatment programs were developed during the 1960s, primarily to help heroin users. Getting addicts off needles, which can spread disease, was seen at the time as a major benefit of treatment.

The drug works by occupying the same brain receptors as heroin and other opioids, such as oxycodone, hydrocodone and morphine — drugs often used as painkillers that can lead to dependence. Quitting can cause aches, chills, vomiting, diarrhea and anxiety.

To be admitted, clients must be addicted to opioids for at least a year. Treatment providers can accept medical records, statements from loved ones and arrest records to determine a person has been addicted for at least a year.

Methadone relieves withdrawal symptoms and combats the craving for opioids. It's cheaper than the other drugs and is excreted so slowly it can be taken once a day. If administered properly, it's not intoxicating. While it produces dependence, if the dosage is slowly reduced over time methadone users can be weaned off without painful withdrawal symptoms.

That doesn't mean it's harmless. Though methadone comprised only 2 percent of painkiller prescriptions in 2009, it was involved in 30 percent of the 15,500 prescription painkiller overdose deaths that year, according to the Centers for Disease Control and Prevention. Because it has a longer half-life than other opioids, it is more likely to build up in a person's body and depress the respiratory system or have adverse reactions with other drugs.

Pill mills and an explosion of painkiller abuse have brought tremendous growth to the methadone industry, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence.

The industry has been identified as one of the most lucrative sectors in health care because of its cash-only nature and high profit margin. In 2006, Bain Capital, the private equity firm co-founded by former Republican presidential contender Mitt Romney, paid $723 million to acquire CRC Health Group, the nation's largest chain of for-profit methadone clinics, according to corporate filings. (Romney left Bain seven years before it acquired CRC.)

The past 10 years have seen about 200 new opioid treatment programs open, a significant amount considering only 1,250 programs are in operation nationwide. Most of those new clinics have been for-profit entities, Parrino said, because states and local governments are reluctant to devote funding to methadone maintenance treatment.

That's the case in Daytona Beach, where the clinic is operated by Colonial Management, which runs 56 other treatment centers in 18 states.

The Daytona Beach clinic's program director referred questions to Colonial Management's corporate office. Mike Ford, director of accreditation and corporate compliance, said company officials would not comment for this story.

Business is good at the Daytona Beach clinic, which serves Volusia and Flagler counties. Last year, it moved from International Speedway Boulevard near Bethune-Cookman University to a nondescript office building near the Veterans Affairs clinic just off Bill France Boulevard to accommodate more patients.

Even with the larger location, the state has determined a need exists for three more clinics in northeast Florida, making it one of the most underserved parts of the state. The northeast region includes Volusia, Flagler, St. Johns and Duval counties, along with 16 other counties. On Feb. 21, Colonial opened a new clinic in St. Augustine.

The next closest clinics are in Orlando, Jacksonville and Brevard County. Flagler County does not have a methadone clinic.

The Daytona Beach treatment center accepts cash, traveler's checks and money orders only — no credit cards or personal checks, according to guidelines given to patients. Medicaid is not accepted, and patients are given little leeway if they are unable to pay.

Profits generated through continued methadone treatment often overlap with what is best for the patient, Parrino said. He compared the treatment to providing insulin to a diabetic or administering cholesterol-lowering drugs.

"The general view is retention (in a methadone program) and treatment is considered favorable, not unfavorable," Parrino said. "I think people look at addiction to drugs in a unique framework. It's an illness. It's a disease, and it's a treatable disease."

A PATIENT'S EXPERIENCE

Tracy Williams used to be one of the people standing outside the Daytona Beach methadone clinic.

Clinics dispense the drug early in the morning with the idea that patients can get their dose and still get to work. Federal and state regulations prohibit patients from receiving take-home doses until they demonstrate they are adhering to the clinic guidelines and are not taking other drugs.

Wanting to avoid long waits, clients arrive early to drink their dose, which must be taken in person to avoid abuse. In Daytona Beach, dosing starts at 5 a.m. on weekdays.

Williams, 29, had been addicted to oxycodone until she was jailed last summer in Volusia County for theft — while she was pregnant.

Because opioid withdrawal can be damaging to a fetus, she was prescribed methadone. A guard took her to the methadone clinic for a daily dose of 20 milligrams, which Williams said should have been sufficient to quell her cravings without intoxicating her.

But she said she kept asking for more methadone as a way to feel high while in jail. The clinic obliged, upping her dosage to 125 milligrams, she said.

"I think a lot of people are using the methadone clinic as a way to get high," she said.

Williams paid the price upon her release from jail.

She was living in Lake County and had to drive to Daytona Beach every morning. Her methadone was costing her $100 a week, more than she could afford. The higher dosage she'd started taking in jail meant it would take her longer to undergo detoxification — if she ever got off the drug.

Counselors were swamped, and it seemed the clinic focused more on dosing than helping patients work through their issues with therapy, Williams said.

Finally, out of options, she recalled coming to the clinic one day with tears rolling down her cheeks. She was seven and a half months pregnant, out of money and still dependent on the drug.

Though 18 of Florida's 35 clinics were licensed during the 2011-12 fiscal year to accept Medicaid, a federal-state program that helps pay for health care for the needy, the Daytona Beach clinic does not.

"They told me there was nothing they could do — pretty much I was left lingering," Williams said.

Abrupt withdrawal from opioids addiction can result in "preterm labor, fetal distress or fetal demise," according to the American Congress of Obstetricians and Gynecologists, which advises physicians to keep dependent pregnant women on methadone through the duration of their pregnancy.

Through her gynecologist, Dr. Pam Carbiener, Williams managed to secure a waiver that allowed her to pay for the drug through Medicaid. But that was far from the end of her troubles.

QUESTIONS ABOUT COLONIAL

Questions have been raised in other states about Colonial Management Group's business practices and its adherence to federal and state regulations.

In September, the Minnesota Department of Human Services issued an order of revocation for a Colonial Management Group clinic in Duluth after inspectors found the clinic had excessive counselor caseloads, insufficient training and "a clearly demonstrated failure by the program director to understand the licensing regulations."

Colonial Management is appealing the state's revocation.

Minnesota's action came two years after a class-action lawsuit filed in Montgomery, Ala., accused Colonial Management of failing to provide counseling. The case was settled, said a spokeswoman for the law firm that brought the suit.

In Florida, counselors at methadone clinics must have a caseload equivalent of no more than 32 clients. The state uses a complex formula based on how often a client must be seen to calculate counselor loads. When inspectors visited the Daytona Beach clinic in September, they found some counselors had caseloads that were two to three times higher than state requirements.

Regulators could have fined the clinic, suspended or revoked its license or issued a moratorium on accepting new patients. But none of those actions were taken.

Instead, the clinic achieved a performance rating score of 94.25 on a 100-point scale.

State officials reviewed the performance rating following questions from The News-Journal. They said at the time the inspection was done, the clinic had just moved into its new building and was under new management. Counselor vacancies have since been filled, officials said, and the clinic is in compliance with staffing levels.

"We are doing a good job of managing methadone as a controlled substance," said Sheila Barbee, team leader for substance abuse with the Department of Children and Families. "This is an area we take very seriously. I think we have good staff in the field, and we have good standards."

In the Minnesota case, inspectors took action after finding recurring excessive caseloads that were similar to what Florida found at the Daytona Beach clinic.

What inspectors found at a Colonial Management clinic in Duluth was troubling, said Jerry Kerber, inspector general for the Minnesota Department of Human Services.

"It is intended in Minnesota to be more than a dose-and-go kind of service," he said. "It's more than picking up methadone and going on their way."

COUNSELING VS. TREATMENT

Methadone treatment isn't necessarily intended to wean patients from the drug. Dr. Kelly Clark, chief medical officer at another for-profit methadone provider, said the larger goal is to ensure patients are achieving their highest level of functioning at the lowest possible dose.

Clark compared methadone doses to a nicotine patch. Even though former smokers are not entirely nicotine free, they are still avoiding cancer-causing chemicals found in cigarette smoke.

A good clinic, whether it's for-profit or not-for-profit, will gain referrals if it is able to help addicts get their lives back, she said.

"I don't think there is any misalignment when there is a profit motive in providing medical care," said Clark, chief medical officer for Dallas-based Behavioral Health Group and a member of the American Society of Addiction Medicine's Board of Directors. "(Opioid treatment programs) are a classic example of doing well by doing good. You do well by doing good work."

Society benefits when addicts are shifted to methadone from costlier, illicit street drugs, said Dr. Bruce A. Goldberger, director of toxicology at the University of Florida College of Medicine.

Methadone treatment stops addicts from trading drugs for sex, injecting or smoking drugs or resorting to theft to support their expensive habit, Goldberger said. The street value of a single pill of oxycodone can be $20, and addicts can spend more than $100 a day on their habit.

Because methadone is slower acting, patients can take their dose once a day and then lead a productive life, he said.

"It's not like we are just swapping one drug for another and letting this person go along with their addiction," Goldberger said.

While no one doubts methadone is a better alternative to heroin, some question the commitment to counseling at the clinics.

While medication can play an important role, counseling is invaluable when it comes to combating drug addiction, said Randy Croy, the longtime director of Haven Recovery Center, a substance abuse treatment program headquartered in Daytona Beach.

"It's my experience that medications without counseling are insufficient to accomplish that goal of getting people clean, sober and productive," Croy said. "Thus, most of us in the treatment world feel that counseling — whether inpatient, outpatient or supportive — is critical to long-term success in recovery."

For clinics that rely on addicts for daily cash payments, there's little incentive to help them break their dependency, said Steven Hayes, who ran the Novus Medical Detox Center in Port Richey and is one of Florida's most outspoken critics of methadone treatment.

"The problem with methadone usage is it's like any other opioid," he said. "If you are not particularly disciplined, you keep seeing the dose go up. Obviously, the clinics profit."

Detoxification and counseling would be the better first approach to helping opioid addicts, Hayes said. Instead, patients — even those who have been using only a short time — start going to for-profit methadone clinics.

"Their profit model is to increase the sale of their drugs," Hayes said. "Are they going to put themselves out of business? Upton Sinclair said, 'It's difficult to get a man to understand something when his salary depends on his not understanding it.' "

Nanette Wollfarth's understanding is simple. Having been hooked on heroin as a teen, she says getting on methadone made it possible for her to have a salary and a normal life.

"I would have been dead — no doubt," said Wollfarth, whose account is similar to a long string of testimonials trumpeting the drug's life-changing possibilities on Colonial Management's website.

Now 64, Wollfarth has been using methadone for 42 years. Without it, she doubts she would have been able to open her own beauty salon. She estimates she and her husband — who also uses methadone — have spent more than $250,000 over the past four decades on the drug.

Based on her experience, Wollfarth, who lives near Gainesville, said younger patients who get on methadone shouldn't expect to wean themselves off the drug in a couple of years.

"It's a lifetime commitment," she said.

NEVER GOT TO HOLD HER

Williams is one of the patients who managed to get off methadone, but it didn't lead to the happy ending she dreamed of while expecting her baby.

Her baby, Heavenlee, was born with gastroschisis, a birth defect in which an infant's intestines stick out of its body. The baby battled for its life for four days before dying in an Orlando hospital.

Williams' doctor said drug use likely played no role in the defect, but the experience had a radical effect on the young mother, and no amount of assurances can assuage her guilt.

"I know the baby died from all the drugs I was using," she said. "Instead of wanting them, I despise them. They took something from me."

Afterward, she immediately entered a detox program to free herself from methadone.

A box filled with memories of Heavenlee rests on a shelf in the hall of Williams' DeLand home. It is a memorial to the daughter she lost — and a reminder of a lifestyle she intends to never experience again.

Inside the box are the baby's bracelet and a tiny diaper that would have fit her 3 pound, 8 ounce body. Pictures of Heavenlee surrounded with tubes are there, too, but Williams can't stand to look at them.

Her hands shook as she removed photographs from the box. As she handed the pictures over, she looked away to avoid catching a glimpse.

"I never got to hold her," she said.

Tears rolled down Williams' cheek as she returned the items to the box and slid it back on the shelf.

Benefits of methadone treatment

Critics of methadone say it just swaps one drug for another and doesn't address the root cause of addiction. In a 2002 fact sheet, the Centers for Disease Control and Prevention found several benefits of methadone maintenance treatment.

- reduced or stopped use of injection drugs

- reduced risk of acquiring or spreading diseases, such as HIV or hepatitis

- reduced chance of overdose; the median death rate of dependent individuals in methadone maintenance treatment is 30 percent of the rate of those not in a methadone treatment program

- possible reduction in sexual risk behaviors

- reduced criminal activity

- improved family stability and employment potential

- improved pregnancy outcomes

SOURCE: Centers for Disease Control and Prevention

Busiest methadone clinics in Florida

Colonial Management Group operates four of the five busiest methadone clinics in the state.

Pill addicts can easily spend hundreds of dollars a week to feed their habit.

But getting access to methadone or another drug to help them quit isn't cheap either. At the Daytona Beach Methadone Treatment Center, clients spend about $100 a week to get their daily dose of methadone.

Buprenorphine, a newer maintenance drug sold under the brand name Suboxone that came to market in 2002, costs even more. Clients will spend $175 per week for this alternative to methadone.

Because of the cash-only nature of the methadone business, addiction and substance abuse treatment providers have emerged "as some of the most sought after — and valuable — acquisition candidates in health care," according to The Braff Group, a Pittsburgh-based mergers and acquisitions company.

Providers in this health care sector frequently run profit margins of more than 10 percent and often approaching 20 percent or more, according to Braff.

Not all clinics are cash-only businesses, though. In Florida, providers can elect to accept Medicaid, which pays up to $67.48 a week for methadone treatment. In total, Florida's Medicaid program paid out $9.5 million for methadone treatment during the 2011-12 fiscal year, according to the Agency for Health Care Administration.

The closest clinics to Daytona Beach that accept Medicaid are in Jacksonville and Orlando.

Rules designed to safeguard against abuse

In some states, concerns are mounting that methadone clinics are contributing to the illicit sale of the drug, as well as overdoses, despite tight regulations on take-home doses.

Clients can take home doses of methadone if they demonstrate good behavior and pass drug screens. After 30 days of compliance, clients can take home one dose a week. That amount increases to up to six doses a week after three years of compliance, according to state regulations.

"It's not completely foolproof because we do see it on the streets," said Dan Danielson, an investigator with the Carlton County Sheriff's Office in Minnesota. "There is a huge amount of pressure on users who bring it home to flip it for cash or trade it for other products."

Locally, illegal methadone sales have not been a significant problem, said Brandon Haught, a spokesman for the Volusia County Sheriff's Office. For the few cases investigators have encountered, it's been difficult to determine where the methadone originated.

To guard against abuse, clinics send doses home in locked boxes and conduct random audits to ensure the medication is taken correctly, said Dr. Kelly Clark, chief medical officer for the methadone provider Behavioral Health Group. Patients who abuse the drug are terminated from the treatment program.

Methadone clinics are being unfairly blamed for overdose deaths and illicit sales, Clark said. A bigger culprit is the prescribing of methadone for pain management, which allows the drug to be taken home in larger batches with less oversight, she said.

Federal authorities have been active recently in ensuring methadone clinics are keeping up with the drugs they dispense.

In March, the U.S. Department of Justice levied a $95,000 fine in a settlement with Colonial Management Group's clinic in Huntsville, Ala., because the clinic could not account for 3,423 doses of methadone. It was the largest penalty ever collected in Alabama in a Drug Enforcement Administration diversion investigation. The clinic denied any intentional violation of regulations and revised its record-keeping at the DEA's request.

<p>DAYTONA BEACH &mdash; It's 5 a.m., and the streets are deserted. </p><p>But at the Daytona Methadone Treatment Center, more than 100 people stand in line for their daily dose of methadone, a drug that helps quell cravings for heroin and oxycodone. </p><p>The orange glows from cigarettes puncture the darkness as a security guard paces in the parking lot. A few people sit in chairs near the entrance of Florida's second-busiest clinic like Black Friday shoppers waiting for a doorbuster sale. </p><p>But this isn't a holiday. It's not a special occasion. For these people, it's a daily ritual. </p><p>As part of the $14 people pay for their daily methadone dose, clients are supposed to have access to counselors to help them with their recovery. </p><p>Yet counselor caseloads at Daytona Beach's methadone clinic have been two to three times higher than what they are supposed to be under state regulations, records show. And fewer than 2 percent of the 1,800 clients served by the clinic were weaned off the drug or successfully discharged from the program during the 2011-12 fiscal year, the last year for which records are available. </p><p>Methadone treatment is seen by the Centers for Disease Control and Prevention and others as an intervention that helps addicts get their lives back. One advocate who's taken a daily dose of the drug for more than 40 years says methadone saved her life. </p><p>At the same time, the treatment has long faced backlash from critics who say it simply swaps one drug for another. For-profit providers like Orlando-based Colonial Management Group, the company that runs the Daytona clinic, have come under fire from those who view them as "dose-and-go" operations that put profits ahead of patient care. </p><p>In Minnesota, inspectors are in the process of revoking the license of a Colonial Management methadone clinic where counselors had similarly high caseloads and other compliance issues. </p><p>In Florida, though, regulators rewarded the Daytona Beach clinic with a performance rating of 94 out of a possible 100 points. </p><p><b>A FOR-PROFIT BUSINESS</b> </p><p>Methadone maintenance treatment programs were developed during the 1960s, primarily to help heroin users. Getting addicts off needles, which can spread disease, was seen at the time as a major benefit of treatment. </p><p>The drug works by occupying the same brain receptors as heroin and other opioids, such as oxycodone, hydrocodone and morphine &mdash; drugs often used as painkillers that can lead to dependence. Quitting can cause aches, chills, vomiting, diarrhea and anxiety. </p><p>To be admitted, clients must be addicted to opioids for at least a year. Treatment providers can accept medical records, statements from loved ones and arrest records to determine a person has been addicted for at least a year. </p><p>Methadone relieves withdrawal symptoms and combats the craving for opioids. It's cheaper than the other drugs and is excreted so slowly it can be taken once a day. If administered properly, it's not intoxicating. While it produces dependence, if the dosage is slowly reduced over time methadone users can be weaned off without painful withdrawal symptoms. </p><p>That doesn't mean it's harmless. Though methadone comprised only 2 percent of painkiller prescriptions in 2009, it was involved in 30 percent of the 15,500 prescription painkiller overdose deaths that year, according to the Centers for Disease Control and Prevention. Because it has a longer half-life than other opioids, it is more likely to build up in a person's body and depress the respiratory system or have adverse reactions with other drugs. </p><p>Pill mills and an explosion of painkiller abuse have brought tremendous growth to the methadone industry, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. </p><p>The industry has been identified as one of the most lucrative sectors in health care because of its cash-only nature and high profit margin. In 2006, Bain Capital, the private equity firm co-founded by former Republican presidential contender Mitt Romney, paid $723 million to acquire CRC Health Group, the nation's largest chain of for-profit methadone clinics, according to corporate filings. (Romney left Bain seven years before it acquired CRC.) </p><p>The past 10 years have seen about 200 new opioid treatment programs open, a significant amount considering only 1,250 programs are in operation nationwide. Most of those new clinics have been for-profit entities, Parrino said, because states and local governments are reluctant to devote funding to methadone maintenance treatment. </p><p>That's the case in Daytona Beach, where the clinic is operated by Colonial Management, which runs 56 other treatment centers in 18 states. </p><p>The Daytona Beach clinic's program director referred questions to Colonial Management's corporate office. Mike Ford, director of accreditation and corporate compliance, said company officials would not comment for this story. </p><p>Business is good at the Daytona Beach clinic, which serves Volusia and Flagler counties. Last year, it moved from International Speedway Boulevard near Bethune-Cookman University to a nondescript office building near the Veterans Affairs clinic just off Bill France Boulevard to accommodate more patients.</p><p>Even with the larger location, the state has determined a need exists for three more clinics in northeast Florida, making it one of the most underserved parts of the state. The northeast region includes Volusia, Flagler, St. Johns and Duval counties, along with 16 other counties. On Feb. 21, Colonial opened a new clinic in St. Augustine.</p><p>The next closest clinics are in Orlando, Jacksonville and Brevard County. Flagler County does not have a methadone clinic. </p><p>The Daytona Beach treatment center accepts cash, traveler's checks and money orders only &mdash; no credit cards or personal checks, according to guidelines given to patients. Medicaid is not accepted, and patients are given little leeway if they are unable to pay. </p><p>Profits generated through continued methadone treatment often overlap with what is best for the patient, Parrino said. He compared the treatment to providing insulin to a diabetic or administering cholesterol-lowering drugs. </p><p>"The general view is retention (in a methadone program) and treatment is considered favorable, not unfavorable," Parrino said. "I think people look at addiction to drugs in a unique framework. It's an illness. It's a disease, and it's a treatable disease."</p><p><b>A PATIENT'S EXPERIENCE</b> </p><p>Tracy Williams used to be one of the people standing outside the Daytona Beach methadone clinic. </p><p>Clinics dispense the drug early in the morning with the idea that patients can get their dose and still get to work. Federal and state regulations prohibit patients from receiving take-home doses until they demonstrate they are adhering to the clinic guidelines and are not taking other drugs. </p><p>Wanting to avoid long waits, clients arrive early to drink their dose, which must be taken in person to avoid abuse. In Daytona Beach, dosing starts at 5 a.m. on weekdays. </p><p>Williams, 29, had been addicted to oxycodone until she was jailed last summer in Volusia County for theft &mdash; while she was pregnant. </p><p>Because opioid withdrawal can be damaging to a fetus, she was prescribed methadone. A guard took her to the methadone clinic for a daily dose of 20 milligrams, which Williams said should have been sufficient to quell her cravings without intoxicating her. </p><p>But she said she kept asking for more methadone as a way to feel high while in jail. The clinic obliged, upping her dosage to 125 milligrams, she said. </p><p>"I think a lot of people are using the methadone clinic as a way to get high," she said. </p><p>Williams paid the price upon her release from jail. </p><p>She was living in Lake County and had to drive to Daytona Beach every morning. Her methadone was costing her $100 a week, more than she could afford. The higher dosage she'd started taking in jail meant it would take her longer to undergo detoxification &mdash; if she ever got off the drug. </p><p>Counselors were swamped, and it seemed the clinic focused more on dosing than helping patients work through their issues with therapy, Williams said. </p><p>Finally, out of options, she recalled coming to the clinic one day with tears rolling down her cheeks. She was seven and a half months pregnant, out of money and still dependent on the drug. </p><p>Though 18 of Florida's 35 clinics were licensed during the 2011-12 fiscal year to accept Medicaid, a federal-state program that helps pay for health care for the needy, the Daytona Beach clinic does not. </p><p>"They told me there was nothing they could do &mdash; pretty much I was left lingering," Williams said. </p><p>Abrupt withdrawal from opioids addiction can result in "preterm labor, fetal distress or fetal demise," according to the American Congress of Obstetricians and Gynecologists, which advises physicians to keep dependent pregnant women on methadone through the duration of their pregnancy. </p><p>Through her gynecologist, Dr. Pam Carbiener, Williams managed to secure a waiver that allowed her to pay for the drug through Medicaid. But that was far from the end of her troubles.</p><p><b>QUESTIONS ABOUT COLONIAL</b> </p><p>Questions have been raised in other states about Colonial Management Group's business practices and its adherence to federal and state regulations. </p><p>In September, the Minnesota Department of Human Services issued an order of revocation for a Colonial Management Group clinic in Duluth after inspectors found the clinic had excessive counselor caseloads, insufficient training and "a clearly demonstrated failure by the program director to understand the licensing regulations."</p><p>Colonial Management is appealing the state's revocation. </p><p>Minnesota's action came two years after a class-action lawsuit filed in Montgomery, Ala., accused Colonial Management of failing to provide counseling. The case was settled, said a spokeswoman for the law firm that brought the suit. </p><p>In Florida, counselors at methadone clinics must have a caseload equivalent of no more than 32 clients. The state uses a complex formula based on how often a client must be seen to calculate counselor loads. When inspectors visited the Daytona Beach clinic in September, they found some counselors had caseloads that were two to three times higher than state requirements. </p><p>Regulators could have fined the clinic, suspended or revoked its license or issued a moratorium on accepting new patients. But none of those actions were taken. </p><p>Instead, the clinic achieved a performance rating score of 94.25 on a 100-point scale. </p><p>State officials reviewed the performance rating following questions from The News-Journal. They said at the time the inspection was done, the clinic had just moved into its new building and was under new management. Counselor vacancies have since been filled, officials said, and the clinic is in compliance with staffing levels. </p><p>"We are doing a good job of managing methadone as a controlled substance," said Sheila Barbee, team leader for substance abuse with the Department of Children and Families. "This is an area we take very seriously. I think we have good staff in the field, and we have good standards." </p><p>In the Minnesota case, inspectors took action after finding recurring excessive caseloads that were similar to what Florida found at the Daytona Beach clinic. </p><p>What inspectors found at a Colonial Management clinic in Duluth was troubling, said Jerry Kerber, inspector general for the Minnesota Department of Human Services.</p><p>"It is intended in Minnesota to be more than a dose-and-go kind of service," he said. "It's more than picking up methadone and going on their way."</p><p><b>COUNSELING VS. TREATMENT</b> </p><p>Methadone treatment isn't necessarily intended to wean patients from the drug. Dr. Kelly Clark, chief medical officer at another for-profit methadone provider, said the larger goal is to ensure patients are achieving their highest level of functioning at the lowest possible dose. </p><p>Clark compared methadone doses to a nicotine patch. Even though former smokers are not entirely nicotine free, they are still avoiding cancer-causing chemicals found in cigarette smoke. </p><p>A good clinic, whether it's for-profit or not-for-profit, will gain referrals if it is able to help addicts get their lives back, she said. </p><p>"I don't think there is any misalignment when there is a profit motive in providing medical care," said Clark, chief medical officer for Dallas-based Behavioral Health Group and a member of the American Society of Addiction Medicine's Board of Directors. "(Opioid treatment programs) are a classic example of doing well by doing good. You do well by doing good work." </p><p>Society benefits when addicts are shifted to methadone from costlier, illicit street drugs, said Dr. Bruce A. Goldberger, director of toxicology at the University of Florida College of Medicine. </p><p>Methadone treatment stops addicts from trading drugs for sex, injecting or smoking drugs or resorting to theft to support their expensive habit, Goldberger said. The street value of a single pill of oxycodone can be $20, and addicts can spend more than $100 a day on their habit. </p><p>Because methadone is slower acting, patients can take their dose once a day and then lead a productive life, he said. </p><p>"It's not like we are just swapping one drug for another and letting this person go along with their addiction," Goldberger said. </p><p>While no one doubts methadone is a better alternative to heroin, some question the commitment to counseling at the clinics. </p><p>While medication can play an important role, counseling is invaluable when it comes to combating drug addiction, said Randy Croy, the longtime director of Haven Recovery Center, a substance abuse treatment program headquartered in Daytona Beach.</p><p>"It's my experience that medications without counseling are insufficient to accomplish that goal of getting people clean, sober and productive," Croy said. "Thus, most of us in the treatment world feel that counseling &mdash; whether inpatient, outpatient or supportive &mdash; is critical to long-term success in recovery." </p><p>For clinics that rely on addicts for daily cash payments, there's little incentive to help them break their dependency, said Steven Hayes, who ran the Novus Medical Detox Center in Port Richey and is one of Florida's most outspoken critics of methadone treatment. </p><p>"The problem with methadone usage is it's like any other opioid," he said. "If you are not particularly disciplined, you keep seeing the dose go up. Obviously, the clinics profit." </p><p>Detoxification and counseling would be the better first approach to helping opioid addicts, Hayes said. Instead, patients &mdash; even those who have been using only a short time &mdash; start going to for-profit methadone clinics. </p><p>"Their profit model is to increase the sale of their drugs," Hayes said. "Are they going to put themselves out of business? Upton Sinclair said, 'It's difficult to get a man to understand something when his salary depends on his not understanding it.' " </p><p>Nanette Wollfarth's understanding is simple. Having been hooked on heroin as a teen, she says getting on methadone made it possible for her to have a salary and a normal life. </p><p>"I would have been dead &mdash; no doubt," said Wollfarth, whose account is similar to a long string of testimonials trumpeting the drug's life-changing possibilities on Colonial Management's website. </p><p>Now 64, Wollfarth has been using methadone for 42 years. Without it, she doubts she would have been able to open her own beauty salon. She estimates she and her husband &mdash; who also uses methadone &mdash; have spent more than $250,000 over the past four decades on the drug. </p><p>Based on her experience, Wollfarth, who lives near Gainesville, said younger patients who get on methadone shouldn't expect to wean themselves off the drug in a couple of years. </p><p>"It's a lifetime commitment," she said.</p><p><b>NEVER GOT TO HOLD HER</b> </p><p>Williams is one of the patients who managed to get off methadone, but it didn't lead to the happy ending she dreamed of while expecting her baby. </p><p>Her baby, Heavenlee, was born with gastroschisis, a birth defect in which an infant's intestines stick out of its body. The baby battled for its life for four days before dying in an Orlando hospital. </p><p>Williams' doctor said drug use likely played no role in the defect, but the experience had a radical effect on the young mother, and no amount of assurances can assuage her guilt.</p><p>"I know the baby died from all the drugs I was using," she said. "Instead of wanting them, I despise them. They took something from me." </p><p>Afterward, she immediately entered a detox program to free herself from methadone. </p><p>A box filled with memories of Heavenlee rests on a shelf in the hall of Williams' DeLand home. It is a memorial to the daughter she lost &mdash; and a reminder of a lifestyle she intends to never experience again.</p><p>Inside the box are the baby's bracelet and a tiny diaper that would have fit her 3 pound, 8 ounce body. Pictures of Heavenlee surrounded with tubes are there, too, but Williams can't stand to look at them. </p><p>Her hands shook as she removed photographs from the box. As she handed the pictures over, she looked away to avoid catching a glimpse. </p><p>"I never got to hold her," she said. </p><p>Tears rolled down Williams' cheek as she returned the items to the box and slid it back on the shelf.</p><p><b>Benefits of methadone treatment</b> </p><p>Critics of methadone say it just swaps one drug for another and doesn't address the root cause of addiction. In a 2002 fact sheet, the Centers for Disease Control and Prevention found several benefits of methadone maintenance treatment. </p><p>- reduced or stopped use of injection drugs </p><p>- reduced risk of acquiring or spreading diseases, such as HIV or hepatitis </p><p>- reduced chance of overdose; the median death rate of dependent individuals in methadone maintenance treatment is 30 percent of the rate of those not in a methadone treatment program </p><p>- possible reduction in sexual risk behaviors </p><p>- reduced criminal activity </p><p>- improved family stability and employment potential </p><p>- improved pregnancy outcomes </p><p> SOURCE: Centers for Disease Control and Prevention </p><p><b>Busiest methadone clinics in Florida</b> </p><p>Colonial Management Group operates four of the five busiest methadone clinics in the state. </p><p>1. Orlando Metro Treatment Center: 2,016 clients </p><p>2. Daytona Methadone Treatment Center: 1,824 clients</p><p>3. Jacksonville Metro Treatment Center: 1,355 clients</p><p>4. Bay Area Treatment Center (Pinellas County): 1,022 clients </p><p>5. Drug Abuse Comprehensive Coordinating Office Inc. (Pinellas County): 800 clients </p><p>* Census numbers are from Dec. 13. </p><p>SOURCE: Florida Department of Children and Families</p><p><b>Getting clean has its costs &mdash; and profits</b></p><p>Pill addicts can easily spend hundreds of dollars a week to feed their habit. </p><p>But getting access to methadone or another drug to help them quit isn't cheap either. At the Daytona Beach Methadone Treatment Center, clients spend about $100 a week to get their daily dose of methadone. </p><p>Buprenorphine, a newer maintenance drug sold under the brand name Suboxone that came to market in 2002, costs even more. Clients will spend $175 per week for this alternative to methadone. </p><p>Because of the cash-only nature of the methadone business, addiction and substance abuse treatment providers have emerged "as some of the most sought after &mdash; and valuable &mdash; acquisition candidates in health care," according to The Braff Group, a Pittsburgh-based mergers and acquisitions company. </p><p>Providers in this health care sector frequently run profit margins of more than 10 percent and often approaching 20 percent or more, according to Braff. </p><p>Not all clinics are cash-only businesses, though. In Florida, providers can elect to accept Medicaid, which pays up to $67.48 a week for methadone treatment. In total, Florida's Medicaid program paid out $9.5 million for methadone treatment during the 2011-12 fiscal year, according to the Agency for Health Care Administration. </p><p>The closest clinics to Daytona Beach that accept Medicaid are in Jacksonville and Orlando. </p><p><b>Rules designed to safeguard against abuse</b></p><p>In some states, concerns are mounting that methadone clinics are contributing to the illicit sale of the drug, as well as overdoses, despite tight regulations on take-home doses. </p><p>Clients can take home doses of methadone if they demonstrate good behavior and pass drug screens. After 30 days of compliance, clients can take home one dose a week. That amount increases to up to six doses a week after three years of compliance, according to state regulations. </p><p>"It's not completely foolproof because we do see it on the streets," said Dan Danielson, an investigator with the Carlton County Sheriff's Office in Minnesota. "There is a huge amount of pressure on users who bring it home to flip it for cash or trade it for other products." </p><p>Locally, illegal methadone sales have not been a significant problem, said Brandon Haught, a spokesman for the Volusia County Sheriff's Office. For the few cases investigators have encountered, it's been difficult to determine where the methadone originated. </p><p>To guard against abuse, clinics send doses home in locked boxes and conduct random audits to ensure the medication is taken correctly, said Dr. Kelly Clark, chief medical officer for the methadone provider Behavioral Health Group. Patients who abuse the drug are terminated from the treatment program. </p><p>Methadone clinics are being unfairly blamed for overdose deaths and illicit sales, Clark said. A bigger culprit is the prescribing of methadone for pain management, which allows the drug to be taken home in larger batches with less oversight, she said. </p><p>Federal authorities have been active recently in ensuring methadone clinics are keeping up with the drugs they dispense. </p><p>In March, the U.S. Department of Justice levied a $95,000 fine in a settlement with Colonial Management Group's clinic in Huntsville, Ala., because the clinic could not account for 3,423 doses of methadone. It was the largest penalty ever collected in Alabama in a Drug Enforcement Administration diversion investigation. The clinic denied any intentional violation of regulations and revised its record-keeping at the DEA's request.</p>